I've Actually Manipulated Someone! Now What?!?

One of the things that makes us better as a health care profession is our emphasis on home exercises. One of the things I always make clear to all patients is, we can help you, but you're responsible for yourself the entire time you're not in our clinic. Compliance is NOT an option, neither is posture, or for most people, deviation from the prescribed HEP frequency/intensity/duration.

As a CertMDT, or Credentialed McKenzie Method PT, I definitely emphasize postural correction and HEP for all spinal patients. I find this works better, not to mention easier for the patient to do than most stabilization programs. If someone gets better without showing them core strengthening or deep cervical flexor exercises, I won't bother with them. If they plateau with only MDT, then I add other approaches. However, the genius of MDT is that it can be done anywhere, and it is VERY effective; if you are assertive enough to make a patient understand not only that they need to do it, but WHY they need to. It can make them better, and once it does, it can prophylacticly keep them better. These exercises initially need to be done 10 reps an hour as a generic example to start.

The failure of most PTs, some of them even Cert's is that they don't make the patient understand they need to get to end range, whether it's cervical, thoracic, or lumbar. The patient will often say they tried the exercise, but it hurt to do it, so they stopped. Maybe it hurt, but did it make them worse? Worse is only if it increases during the motion, and REMAINS worse. Ironically, I am the best example of this. I wake a few times a year with a cervical derangement or acute facet lock (whichever you prefer, to me they're the same thing, different name). If someone I was training was good enough to manipulate me, great! I'd gladly accept one, and continue with cervical retractions. Two years ago, this happened to me, and none of my current students were proficient using their left hand. I really needed a lower cervical translatory thrust as I had acutely painful sidebending and rotation to the left, and extension was also blocked. Cervical retraction and extension exercises were painful, but did not make it better.

At this time, I just happened to be attending a McKenzie Clinical Skills Update course. The instructor was saying to try cervical retraction with SB and overpressure. I thought, what the hell, "end range is where the magic happens!" I retracted and pulled to the left, harder and harder, moving further and further. At first, it hurt like hell! It did not REMAIN worse, but really didn't change for the first 2-3 hours. Then it happened, it gradually got easier. I began to pull even further into end range sidebending left, so much that my right upper trap felt like I was tearing it. After several hours of doing this exercise 30-40 times/hour. I was nearly pain free and most of my motion had returned.

Would a cervical thrust manipulation do the same thing? Absolutely! Would it have been easier on me as a patient? Sure? Would most patients go nuts into the painful/obstructed direction like I did? Most likely not, they would think they're injuring themselves, when in reality, they don't give it enough time, force, and repetitions.

Where manipulation comes in is for the patients who can't push themselves. A recent award winning JMMT study showed that patients who met the CPR for lumbar thrust manipulation also fit neatly into the lumbar derangement syndrome category. Well, of course they do! Both can rapidly change! I'm sure if the same methods were applied for cervical derangement and the CPR for thoracic/cervical thrust manipulation, the same would hold true. Manipulation makes the derangement more easily reduced by the patient. If their exercises are less painful, you'll have more compliance. In my experience, it doesn't make them any more reliant on you, and they still get discharged within that magic 6-8 visits for most acute conditions.

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